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Form # 8638 (04/15) 8638 Hospital/ Facility Name: ___________________________ Date: ________________ Street: _________________________________ Pt. Name: ______________________________ City: _________________________________ D.O.B. _________________________________ State: _________________________________ SS # ___________________________________ Phone: _________________________________ Last Done:______________________________ Fax: Other Name(s) Used:______________________ _________________________________ PATIENT AUTHORIZATION: Patient Signature:____________________________________________ Date:___________________ We would appreciate the loan of any and all original mammography films, CD’s and reports on the above patient. This is at the request of our Radiologist for comparison to her most recent films. We will return films to you as soon as they have been reviewed in accordance with MQSA Final regulations 21 CFR 900.12 (cc)(4)(ii)(iii). Please mail them to the address marked below: ¨ Kalkaska Memorial Health Center ¨ Munson Healthcare Cadillac Hospital ¨ Munson Healthcare Women’s Imaging Center 419 S. Coral Street Kalkaska, MI 49646 (231) 258-7510 Fax: (231) 258-7669 Radiology Department 400 Hobart Street Cadillac, MI 49601 (231) 876-7260 Fax: (231) 876-7855 ¨ Paul Oliver Memorial Hospital Women’s Imaging Center 224 Park Avenue Frankfort, MI 49635 (231) 352-2225 Fax: (231) 352-2222 Smith Family Breast Health Center 1105 Sixth Street Traverse City, MI 49684 (231) 392-7100 Fax: (231) 935-0437 ¨ Munson Healthcare Grayling Hospital Breast Imaging Department 1100 Michigan Avenue Grayling, MI 49738 (989) 348-0350 Fax: (989) 348-0426 By signing above, the patient has authorized your release of past mammography films, CD’s and reports to this facility. MAMMOGRAM FILM RELEASE REQUEST